Does the CMS Opioid Misuse Strategy Miss the Mark?

The Centers for Medicare and Medicaid Services (CMS) recently released its Opioid Misuse Strategy, a 30-page report containing recommendations to reduce the national opioid abuse epidemic.

CMS likely based the report on these eye-opening statistics: fatalities from drug overdose, including prescription opioids, are now the leading cause of death in the United States and prescription and illicit opioids killed more than 33,000 individuals in 2015. In addition, 6 out of every 1,000 Medicare patients and nearly 9 out every 1,000 Medicaid patients are diagnosed with opioid use disorder. Those rates are approximately 10 times higher than patients with private insurance. Is it any wonder CMS has made addressing the opioid epidemic a top priority?

The report provides recommendations for reducing opioid use disorders, overdoses, inappropriate prescribing, and drug diversion. One of the recommendations would allow pharmacists to identify and report physicians with potentially illicit prescribing practices or beneficiaries who may be overusing opioids.

Bob Twillman, PhD, executive director of the Academy of Integrative Pain Management, commented on that controversial recommendation and why he believes CMS’s efforts to curb opioid use miss the mark.

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What do you think CMS is trying to accomplish with the recommendations?

CMS seems to be trying hard to implement reasonable strategies to ensure that opioid prescriptions are appropriate and provided in a safe manner. Three of their four strategies are unlikely to receive any pushback: increasing naloxone distribution, improving screening and treatment for substance use disorders, and increasing use of evidence-based pain management practices. The one strategy that will cause some concern is the effort to manage prescribing and dispensing practices based on patient profiles and pharmacy management techniques.

Do you think the reasons behind CMS’s increased scrutiny on opioid prescribing practices are valid?

I think there are valid reasons to be concerned about our current patterns of opioid prescribing — we rely on opioids as our primary, and sometimes only, treatment for pain to far too great an extent. Greater discernment on the part of prescribers is clearly warranted. The challenge is not so much in reducing opioid prescribing, but in coming up with other effective treatments for patients who still experience pain after their opioids are taken away. CMS could help us tremendously by increasing coverage for non-pharmacological treatments under Medicare and Medicaid.

Is the 90 morphine milligram equivalent daily dosage limit that CMS proposed an adequate amount to treat most chronic pain?

It’s sufficient for most patients, but not for everyone. That’s why the daily dose should never be made a hard-and-fast rule. I’m OK with using it as a threshold, beyond which added protocols need to be followed — such as referring patients to a pain specialist — but it should not be established as a limit. There are some patients with chronic pain, even pain unrelated to cancer or associated with palliative or end-of-life care, who need opioids to achieve the best possible outcomes. I‘m concerned that CMS’s proposal will result in some patients being unable to get the therapy they need, and I’d much prefer that some other mechanism be worked out.

Do you think it's practical to ask pharmacists to report physicians who are suspected of inappropriate prescribing practices?

A couple of years ago, the Academy of Integrative Pain Management co-sponsored a series of programs designed to encourage prescribers and pharmacists to work more closely together, for their benefit and for the benefit of their patients. Deputizing pharmacists and asking them to report prescribers is fraught with all kinds of problems, and I think it just adds another layer of tension to relationships that are already far too contentious. Patients are best served when their healthcare professionals work together as a team and this policy, I fear, will only serve to destroy teamwork.

What can physicians and pharmacists do to optimize the effective and safe use of these powerful painkillers?

Education needs to be the top priority. We have a huge hill to climb in educating healthcare providers about how to safely and effectively manage pain. We also have huge challenges with reimbursement; part of the reason we overuse opioids now is that they are inexpensive, quick to prescribe, and easy for patients to take. Other effective methods, especially non-pharmacological treatments, are so poorly reimbursed that they are effectively out of reach for most patients. We need to have prescribers and pharmacists approach and educate policymakers about the reasons we’ve gotten to where we are, and about what they can do to help us provide better patient care.

—Dan Cook